Abstract
The aspiration to prevent schizophrenia and other major mental disorders through routine, opportunistic, selective and indicated screening of general practice populations, belies very real practical constraints for individual general practitioners (GPs). This point is ably made by the preceding articles by Professors Harris [1] and Falloon [2]. These and further feasibility issues will be discussed here in relation to the current mental health policy environment and the results of a national survey of Division of General Practice program approaches.
Professor Falloon, in ‘General practice recruitment for people at risk of schizophrenia: the Buckingham experience’, writes from the perspective of specialist psychiatry's optimism for engaging GPs in partnerships for prevention. Yet his paper moves rapidly from screening to shared management or ‘shared care’, using a somewhat more restricted definition of the latter term than that presently understood in general practice [3].
Professor Harris writes from the perspective of delivering mental health care as an everyday experience of GPs. In ‘General practice recruitment for schizophrenia prevention studies’, he outlines barriers for GPs in engaging with the prevention agenda. He notes that infrequent contact with people who have low prevalence disorders limits the acquisition of honed assessment skills. Discontinuities in care quality begin at the first point of assessment, as a result of transient patient populations in general practice. Astute detection of vulnerabilities relies upon knowledge of family history in stable patient populations. The same constraints would seem to reduce opportunities to ‘monitor closely’, as Falloon suggests, those individuals with risk factors for psychosis, once they are detected by the GP (particularly if monitored by the GP on his/her own).
Without saying so directly, these authors point to a conceptual framework for optimising the potential of general practice as a setting for prevention, which begins with indicated prevention but includes the treatment and maintenance ends of the “spectrum of interventions of mental disorders” [4]. That is, GPs are unlikely to participate in screening and case identification without assurances of corresponding responsiveness of specialist mental health services to assist in the care of patients needing treatment. Prevention and service integration then are twin agendas. Thus, these papers are not merely about recruitment of GPs and patients for screening, but are equally about capacities, both in general practice and in mental health services, to be architects of collaborative research coalitions as well as reorganised collaborative systems of mental health care.
While the present mental health policy emphasis on partnerships with primary care [5] might be acknowledged here as progressing readiness for these aspirations, these articles are nonetheless provocative. First, they presuppose that informed GPs could be compelled to participate in routine opportunistic screening, including targeted screening for low prevalence disorders, in sufficient numbers, if given some practice-based incentives. Second, they are provocative in that they invoke the necessity, rather than the ‘add-on’ or optional extra, that screening programs be supported by responsive treatment planning with specialist mental health services. This, in turn, presupposes that appropriate secondary and tertiary service models exist, with sufficient clinical expertise dispersed across all services for the differential diagnosis and management of prodromal and first-onset psychosis. Both of these prerequisites for prevention (engaging sufficient GPs and responding to identified cases) warrant exploration.
The second point will be discussed first. Given the higher probability of suicide in those with psychotic disorder [6], the recent evidence amassed from the National Youth Suicide Prevention Strategy evaluations is relevant here. Many programs, including specialist services, suggested that clinicians working with severely mentally disordered young people at risk for suicide, lack sufficient and appropriate assessment and therapy skills [7],[8], including for working with those with early psychosis. Where these therapies do exist, some years of planning and preparation have underpinned an integrated care approach [9] with the capacity of engaging young people in treatment. It is not GPs alone who are insufficiently skilled in these areas. Rather, the experts themselves recognise the need for better service organisation, protocols for linking with other services and upskilling.
Falloon and Harris raise major, not insignificant, structural workforce preparation and resource challenges for the delivery of mental health care that is capable of early capture and prevention of much of the morbidity associated with schizophrenias. Moreover, to optimise GP roles in prevention tasks, engagement with general practice is needed not just in the re-configuration of the delivery of care once cases are identified, but at the front-end, in research and development for feasibility trials.
Further barriers
Perhaps the greatest barrier to mobilising primary care for prevention of schizophrenias is that it would require a critical mass of clinicians in both systems, not just in general practice, to promote both screening and responsiveness postscreening, for patients identified as in need of care or monitoring. How might this critical mass of convinced and prepared clinicians be mobilised?
In discussing ‘how to choose what to deliver’, Ustun [10] identifies four criteria to mobilise prevention activities in primary care. These are:
Frequency: how common is the condition?
Severity: what are the consequences for the individual, family and community?
Availability of interventions: are they available, effective and acceptable?
Public concern: how much concern do people and policy makers show about these conditions and interventions?
Falloon and Harris address constraints stemming from frequency concerns as to the worth of screening for low prevalence disorders in general practice. There is little if any disagreement as to the severity of schizophrenias warranting prevention. It might also be argued that there is now more adequate public concern for the prevention of mental disorders. This concern is underpinned by enhanced public awareness of the burden of mental disorder and suicide, particularly among the young. It is expressed through bi-partisan support for renewed national suicide and mental health strategies. The remaining precondition for mounting prevention in primary care then is the availability of interventions that are both effective and acceptable.
Divisions of General Practice mental health programs
Mental health program models used by Australian Divisions of General Practice
Psychosis-related programs come fourth after depression and suicide-related interventions. While suicide is a rarer event than psychosis, suicide ideation and attempts are not. Risk of suicide will increase in populations with psychosis. While predicting suicide is not feasible through screening, detecting the clusters of symptoms as prerequisites for suicidal behaviour can be addressed by GPs. Falloon suggests that suicidal ideation is a marker for the prodromal phase of psychosis. This information may assist the positioning of screening programs and related research activity and decision making regarding the focus of screening by GPs in mental health. Screening for clusters of mental disorders, rather than just prodromal psychosis, would be ideal.
The challenge for Division programs is to promote, in the GP, a high index of suspicion for, and build capacities to respond to, any mental disorder among apparently well patient populations. However, the experience of many Divisions is that doctors are difficult to engage in robust, repeated training experiences in these areas and other forms of interventions including shared care. Enhanced recruitment in wide-spread screening, even among adolescents and young adults, would necessitate the diffusion of compelling justifications for, and evidence for outcome, for opportunistic targeted screening programs to particular patient groups.
Clinical practice guidelines are another available technology and often include recommendations about the efficacy of screening. Although there is limited experience in guideline use in general practice in mental health topics, and virtually no impact evaluation in the Australian context, new guidelines are anticipated in mental health topics. Guidelines for early psychosis have been available since 1998 [11], although they appear not to have been systematically disseminated to GPs.
The guideline diffusion literature suggests barriers, further to those offered by Harris and Falloon. Barriers for GPs in adopting recommendations for screening include lack of outcome expectancy, or the attitude that there will be insufficient immediate benefit to particular patients, inertia of previous practice and external barriers, such as no services to which to refer [12]. This framework supports Falloon's suggestion that screening low prevalence disorders or risks (e.g. psychosis or suicide attempts) may not be an optimal strategy for engaging GPs in routine screening, other than in the context of research. There is a need for GP perceptions of outcome expectancy to be translated from the individual patient and practice to a population outcome expectancy in order for the adoption of scientifically sound screening initiatives to take effect. Divisions are well placed to encourage this population health perspective.
Preparing the ground for readiness
The promotion of universal psychological screening in the 13–24 age group is presently underway in a national pilot guideline dissemination program of NHMRC ‘Guidelines Depression in Young People for GPs’. These guidelines contain the recommendation for routine simple screening through assertive questioning of a psychological nature. They provide examples of probing questions on inner feelings and depression. Where depressive disorder or symptoms are elicited, screening for suicide risk, without the use of instruments, is recommended.
The widespread implementation by Divisions of this guideline would promote first-order screening of most risk markers and clinically significant presentations of mental disorder, including substance misuse. However, more rigorous assessment, differential diagnosis and care planning is implicated for GPs, in cases detected as at risk. The primary care role is to initiate care, not manage illness alone in the case of psychosis.
While this pilot sounds promising, even the most simple screening regimen in general practice, particularly in young people, and as measured through practitioner adherence to these guidelines, will require sustained activities, reminders, resource development and education by Divisions. Falloon and Harris have not suggested how more sophisticated screening might be diffused to sufficient numbers of GPs in the absence of guidelines and with sufficient momentum to motivate the related cooperation discussed previously. Then there are issues of cost for these interventions.
National policy initiatives presently underway in mental health each suggest a key role for the GP in screening, enhanced case identification, initiating management and forming partnerships for treatment. Additionally, funds have been allocated to State Health Departments and tied to indicators for demonstrating links between primary and specialist mental health care. These initiatives enhance the possibility of reducing structural barriers to mental health shared care and joint training of GPs in mental health. But the questions of what to screen for, when and how to manage the floodgate problem remain.
It is worth mentioning that in the United Kingdom, through the Defeat Depression Campaign, and in the United States, through the National Depression Screening Day [13], snapshot approaches to screening have been evaluated as successful. In Australia, the nongovernment sector has initiated similar awareness days, chiefly in National Mental Health Week and related awareness days and weeks. These approaches provide alternative entry points for case identification of untreated populations and aim to enhance mental health literacy in the population. This may add momentum for GP screening.
Conclusion
Professors Harris and Falloon acknowledge that prevention necessitates an organised response by both primary and specialist mental health care services, and clinical responsiveness to those with risk factors for mental disorder. At a time for heightened optimism about prevention and promotion in the mental health field, this debate as to feasibility and the respective roles, relationships and responsibilities of particular practitioners and settings must occur. There is now policy readiness for significant effort to be directed toward the diffusion of evidence to practice, through guideline development, service reform and continued reorientation of the field for participating in prevention tasks. Divisions and guidelines both play a potential role in the recruitment of GPs to prevention. However, a sizeable research, development and evaluation agenda pertaining to screening in general practice must underpin such momentum.